Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation

Growth monitoring had become a regular and well-planned activity at the Anganwadi center.

Most mothers acknowledged the usefulness of growth monitoring.

Mothers conceded their inability to remember growth monitoring dates; hence, frontline health workers' repeated mobilization of the community was useful.

Most mothers were willing to bring their children for growth monitoring. Resistance to growth monitoring in the community mainly stemmed from practical difficulties (time, work pressure, and migration), rather than issues of cultural acceptance.

Home visits by frontline health workers were well-accepted and welcomed by the community.

Frontline health workers had been well-trained technically. In addition, most had been trained in and had acquired the soft skills for approaching households as well as for tailoring information.

There was considerable oversight of frontline health workers that also played a role in ensuring home visits happened regularly and appropriately.

Some severely wasted children required more visits than those required as per protocol; the frontline health workers often did not record why and when these additional visits were done in the monitoring software.

There was a need for training frontline health workers on information pertaining to the entire household rather than focusing on mothers alone.

Health camps were held regularly.

The community perceived health camps to be useful, mainly due tothe easy access to free medicines and tonics.

Field staff felt that the main use of health camps was in confirming whether children were anthropometrically wasted or not.

The partnership with NRRC and the adjoining government hospital worked well for the program. The community often reported that frontline health workers referred them to the government hospitaland even accompanied them there if required.

Health camps, when established, were meant specifically for wasted children and pregnant mothers. But it was difficult for camps to turn away other sick children; hence, the camps were largely being used as general health camps for all children, which made them crowded.

The logistics for supply and distribution of medical nutrition therapyin the program had been clearly set by the time of scale-up of the program. A checklist format had been developed for tracking medical nutrition therapy consumption of each child; these checklists were being monitored closely.

Consumption of medical nutrition therapy in the program was lower than expected. It was therefore difficult to make strong conclusions on the effectiveness of medical nutrition therapy in this context.

Overseeing compliance of medical nutrition therapy consumption by frontline health workers was challenging. Frontline health workers delivered several days of cups at a time to a child, but consumption by the child was self-reported by the mother.

While there were no serious issues with logistics (supply and storage) of medical nutrition therapy, there were mothers who found it difficult to feed the medical nutrition therapy cups to the severely wasted child for the full course of 56 days. Mothers and frontline health workers noted that some children got bored of the sweet flavor of the medical nutrition therapy and refused to eat it after a few days. There have been cases of children being pulled out of therapy due to persistent diarrhea or mere refusal to consume.